The Other Uproar in Germany: The Midwife Crisis

Before the recent historical win by Germany in the World Cup Championship and the riotous parties in the streets, there were other strong magnets to Berlin by young outsiders. A new generation of international women have been flocking to Berlin for its green, woman-centric, and family friendly culture.

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Camalo Gaskin
Founder BIRTHtoBIRTH.com a platform for curated resources and thought on birth, mobility, and the importance of being wild. She is a storyteller, doula, translocalist, + Mamma.

Before the recent historical win by Germany in the World Cup Championship and the riotous parties in the streets, there were other strong magnets to Berlin by young outsiders. A new generation of international women have been flocking to Berlin for its green, woman-centric, and family friendly culture. These women see plant-based diets, yoga, and individualized approaches to medicine as mainstream lifestyle choices.

This image, however, could be under threat. Research shows that midwifery care is one of the safest and most cost effective models for the majority of women giving birth. As this information spreads, through word of mouth or social media, desire for midwifery care is becoming a rising trend for young women reimagining approaches to birth. But that care is being reduced all over Germany because of insurance regulations that are being mirrored in EU legislation.

What is the midwife crisis?

In the German language sphere there has been a recent uproar. Petitions have been circulating in the last several months to warn the public of the threat to the midwifery profession and women's choice to birth where and how they wish.

These petitions have been calling on wellness and women's choice advocates, as well as current and expectant families to put pressure on the German government's health minister to come up with a solution to the massive increases in insurance rates on midwives, especially those who assist in birth.

While doing research on global midwifery, mobility, and birth culture, I was astonished to stumble upon this news. In what some refer to as a "spontaneous birth", my first child was born safely at home in the bathtub. This took place in the US, with the assistance of my partner. In preparation for birth, we relied heavily on information and educational resources from midwives who pointed to European birthing models like those in Germany, Scandinavia, and the Netherlands as ideal frameworks for modeling US birth policy. So when I was planning my second home-birth, in Germany, with a midwife, it was an option I completely took for granted.

I sifted through coverage in news outlets all over Germany, health minister statements, the German Midwives' Association press releases and spoke to numerous parents and aware and opinionated citizens. I also spoke with several midwives, including Jitka Nickel of the Berlin Midwives' Assocation and my own midwife, Katharina Perreira, who has been offering her services in English over the last decade.

What are the key issues underlying the controversy?

EU legislation requires professional indemnity insurance for all healthcare professionals. However, it combines midwifery with obstetrics in terms of risk assessment. German insurance policy seems to reflect this analysis. Under the same pressure, independent midwives in the UK were able to successfully demonstrate that statistics for midwifery alone shows a much lower risk factor. This allows them to avoid the unaffordable rate increases.

The liability insurance rate increases for midwives attending births are the steepest. According to the Berlin Midwives' Association's Jitka Nickel, these insurance hikes impact all midwives, but the highest rates apply to roughly 3500 midwives who attend births. This includes 5% who specialize in childbirth at home or in birthing centers, and an additional 30% of attending midwives who assist births in hospitals. The increases have already resulted in many midwives and birthing centers being forced out of practice.

The German Midwives' Association reported the following timetable indicating the rises in annual liability insurance premiums for midwives, rises not reflected by increased risk factors or earnings:

1981 30,68 Euro

1992 178,95 Euro

2003 1218,00 Euro

2009 2370,48 Euro

2010 3689,00 Euro

2012 4242,35 Euro

2014 5091,00 Euro

These premiums are expected to continue rising.

Midwifery is not a highly paid profession. Although earnings vary for midwives, independent midwives earn an average of 630 euros/birth or 8.50 euros/hour. There is not enough data released from hospitals, however midwives who serve both clinic and out-of-hospital births report that they receive around 260 euros/birth.

There is high demand and low supply. Due to the level of high quality personalized care, according to Katharina Perreira, most freelance midwives can serve a maximum of 3 births per month, or 30 births per year when working full-time. When speaking with midwives, I learned that on average they serve 2 families as the lead midwife, and assist 2 additional births led by other midwife colleagues, per month. With the spread of positive reviews about midwifery, most midwives cannot meet the demand. To better gauge the demand, a site has been set up by the German Midwives' Association for women to report when they are unable to find a midwife.

In addition to assisting during birth, midwives provide personalized care throughout pregnancy and oversee the health and well-being of the mother, partner, and baby for 6 weeks following birth.

Midwives' cumulative knowledge about birth is critical. Women particularly benefit from the expertise of midwives during birth, not just during prenatal and postpartum care. But because very few practicing midwives can afford the insurance increases, the majority will only be able to provide prenatal and postpartum support. Their critical expertise around birth support will be lost.

Insurance options are vanishing. Three insurance companies have banded together to become the sole providers of insurance to midwifery professionals. This body dictates insurance rates with no competition. With pressure from women's health interests groups, the Health Minister for Germany has negotiated with a group of additional insurers to cover a small percentage of the liability insurance until July 2016. At that point only two of the main companies plan to continue coverage, but may be out of reach for all practicing midwives.

More transparent data from Hospitals is needed. With a majority of births taking place in the hospital, most hospitals have a rotating staff to address the needs of its patients. Families can not expect continual care, as they do with out-of-hospital midwifery care. Although many report an impression that hospitals are over-subscribed, there isn't enough data released to determine where childbirth improvements can be focused to benefit birth outcomes.

Is there a benefit to midwifery care?

Midwives have long been seen as natural birth experts in that they rely on mechanisms of women's natural physiology, and are adept at detecting any deviations. According to my own midwife Katharina Perreira, founder of the Hebammerie in Kreuzberg, there has been a longstanding recognition of their value in German law. She explained that "there are three legislative clauses that our profession relies on to protect the role of the midwife in Germany. The first states that no physician is permitted to perform birth procedures without the presence of a midwife. The second states that every woman's choice in birth place must be honored and protected. The third states that midwives must be covered by insurance when practicing."

In Germany, awareness of the benefits of midwifery care in and out of hospital is relatively high. Since Marjorie Tew's 1977 study on safer birth in the UK, many other studies have recognized that home birth under midwifery care is a more straightforward, lower risk and a more cost effective option than in most hospital environments.

Speaking with pain management expert and global midwife trainer, Julie Bonapace, founder of the Bonapace Method, I learned that "although some regions like Canada are shifting towards physiology focused midwifery training, many places like France are decreasing the role of midwives during birth by training them in the use of technology rather than physiology, which in turn decreases the depth of knowledge and critical role they play in improving women's experience of childbirth in general."

Furthermore, Julie Bonapace, doula Indira Lopez-Bassols, and hynobirthing expert Katharine Graves, each independently explained that one of the important practices in midwifery is to reduce interventions and allow for women's physiological mechanisms to release in-built pain management hormones to decrease the need for other interventions that may cause complications leading to further (more critical) interventions.

Julie Bonapace expanded on the significance of the role midwives, doulas, and other birth partners play during childbirth in aiding physiological pain management systems. She explains that conditions of support, confidence, security and relaxation activate a mechanism referred to in her analysis as control of the higher centers of the central nervous system (CNSC). This allows the brain to modulate the potentially painful stimulations, such as labor contractions, by conditioning the areas which are responsible for memory, emotions, and reaction to pain. Furthermore, other models like the gate control theory of pain explains the usefulness of creating light stimulation of the painful areas, practiced in more individualized and hands-on approaches to childbirth."

Prominent surgeon, obstetrician, and prolific childbirth researcher Dr. Michel Odent shared with me in a recent conversation a reflection of a World Health Organization report on the rising rates of c-sections in Germany, even in comparison to France. His work has provided critical information about a french maternal healthcare system, where women's birth choices (including independent midwifery care and home births) has been usurped by a medical system which favors interventions.

He suggests that the current lack of understanding of birth physiology would make such inventions within this environment necessary. This trend in interventions highlights the global importance of options like independent midwifery practice, which encourages improved outcomes for women by relying on birth physiology and turning to interventions only when signs are clear that there is a deviation from the norm.

Does Germany fit the "green" ideal?

Germany has long been known as a hub for progressive healthcare and alternative education trends in the mainstream, starting worldwide trends with such things as homeopathy and Waldorf schools. Support for women who wish to thrive in both their career and family life is also covered in German legislation. High quality childcare costs a fraction of the rates in the UK and the US. Germany offers up to 14 months of maternity and paternity benefits, which actively encourages co-parenting, and places emphasis on the value of both parents being present and engaged in the early years of a child's life. Even more invitingly, bilingual services and experimental schools have cropped up all over the capital city of Berlin. With the foundation for supporting families with a wellness focus in place, the desire for improved birthing options in Germany is further prioritized.

Why is this relevant to women globally?

Mobility has been a growing theme for young women everywhere. Places like Berlin are fertile soil for this class of creative, resourceful, green thinkers seeking to launch new lives and projects. The wider support for raising children and career growth invites women and their partners from all over the world to view Germany as an ideal. It also builds an expectation that wider birthing options will reflect a women-centric national agenda.

English is one of the unofficial second languages in Berlin, with a majority of newcomers using it as their second, third, and sometimes even fourth language. But language flexibility is not the only magnet. Because they have greater access to lifestyle magazines and online platforms that promote a wellness culture globally, young women are seeking cities that readily offer more green options. They are embarking on family planning and looking for health care systems that will provide greater support for their long-term preferences.

What can we do now?

Jitka Nickel, the vice chairwoman for the Berlin Midwives' Association shared with me that the problem for many midwives and the growing numbers of families they serve is that "from July 2016 there will no longer be any viable insurance options. This and many other problems must be resolved by politicians, otherwise in just a few years there will barely be any Midwifery care as we know it today, throughout all of Germany."

The demand for midwifery care is on the rise, especially for birthing center births and home births. The availability of midwives is going to drastically decrease if the insurance expense trajectories continue. We need to heighten global awareness of the effects of these trends and put pressure on both health ministers and insurance providers to recognize the breadth of evidence-based benefits in covering the costs of birth support. We must demonstrate the need and growing desire for these services: wellness services that underlie a global agenda to improve women's birth experiences here, and everywhere.

Camalo Gaskin is founder and writer at BerlinManual.com, a platform for curated resources, courses and thought on birth, mobility and the importance of being wild.